Indiana University Health Arnett Hospital

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 49709 Based on document review and interview nursing services failed to document patient pain location, failed to implement interventions for pain, and/or failed to complete pain intervention reassessment for 4 of 10 medical records (MRs) reviewed (P1, P5, P6, and P7). Findings include: 1. Review of policy/procedure titled, “Mother & Child: Epidural & Intrathecal Analgesia,” Publication date 02/27/2024, indicates the following: Under I. Purpose: A. All patients have the right to appropriate assessment and management of pain as appropriate to the patient’s condition. VI. Procedure: a. RN must continually assess the patient for pain, any type of pain. If the patient is experiencing pain, the RN should contact the Obstetric Anesthesia Services Provider who performed the procedure or his/her partner covering call to receive orders for pain management. d. Monitor for the following parameters: vi. Pain score 2. Review of policy/procedure titled, “Adult Pain Management,” Publication date 08/03/2023; indicates the following: Under I. Purpose: All patients have the right to appropriate assessment and management of pain. VI. Procedure: B. Establish realistic pain goals based on functional ability/status. If it is anticipated that the patient will have pain with an activity pharmacologic intervention is appropriate even if the patient is at or below the identified comfort-function goal. C. Reassess and respond to the patient’s pain plan throughout the RN’s shift. If current pain management plan not effective, consider implementation of additional interventions if appropriate or contact patient’s provider. 3. MR review for P1 indicated they had placement of an epidural. MR review of pain assessment using pain scale of 0 - 10, indicated on 10/20/24 at 4:45 p.m., P1 rated their pain at 3, intervention included breathing techniques, pain goal was 3, P1 did not have follow up pain assessment completed. On 10/20/24 at 7:30 p.m., P1 rated their pain at 2, intervention included breathing techniques, pain goal was 3, P1 did not have follow up pain assessment completed. On 10/20/24 at 10:00 p.m., P1 rated the pain in their abdomen at 5, intervention included breathing techniques, P1 did not have follow up pain assessment completed. On 10/21/24 at 4:45 a.m., P1 rated the pain in their head at 3, intervention included medication, P1 did not have follow up pain assessment completed. On 10/21/24 at 1:00 p.m., P1 rated the pain in their abdomen at 3, intervention included medication, pain goal was 3, P1 did not have follow up pain assessment completed. On 10/21/24 at 7:30 p.m., P1 rated their pain at 4, documentation lacked pain location, did not receive any pain interventions, did not have a pain goal, and did not have follow up pain assessment completed. On 10/22/24 at 4:48 a.m., P1 rated their pain at 7, intervention included medication, documentation lacked pain location, P1 did not have follow up pain assessment completed. 4. MR review for P5 indicated they had placement of an epidural. MR review of pain assessment using pain scale of 0 - 10, indicated on 10/25/24 at 2:49 p.m., P5 rated their pain at 4 and did not have follow up pain assessment completed. On 10/25/24 at 4:00 p.m., P5 rated their pain at 3, did not have any pain interventions, and did not have follow up pain assessment completed. On 10/26/24 at 2 a.m., P5 rated the pain in their back and abdomen at 10, interventions included pain medication, breathing techniques, massage, reposition and significant other, P5 did not have any pain assessment follow up. On 10/26/24 at 4 a.m., P5 rated the pain in their back and abdomen at 6, interventions included breathing techniques, massage, reposition and significant other, P5 did not have any pain assessment follow up. On 10/26/24 at 5:30 a.m., P5 rated the pain in their back and abdomen at 6 interventions included breathing techniques, massage, reposition and significant other, P5 did not have any pain assessment follow up. On 10/26/24 at 9:04 a.m., P5 rated the pain in their perineum at 6, interventions included breathing techniques, reposition and emotional support, P5 did not have follow up pain assessment completed. On 10/27/24 at 8:20 a.m., P5 rated their pain at 2, did not have any pain interventions, and did not have follow up pain assessment completed. 5. MR review for P6 indicated they had placement of a spinal block. MR review of pain assessment using pain scale of 0 - 10, indicated on 10/31/24 at 11:26 a.m., P6 rated their pain at 5, documentation lacked location of pain, and intervention included pain medication. On 11/01/24 at 2:55 a.m., P6 rated their pain at 5, documentation lacked location of pain, intervention included pain medication, P6 did not have follow up pain assessment completed. On 11/02/24 at 1:03 a.m., P6 did not have a pain rating, documentation lacked location of pain, intervention included pain medication, and did not have follow up pain assessment completed. On 11/02/24 at 9:29 a.m., P6 rated their pain at 7, documentation lacked location of pain, intervention included pain medication, P6 did not have follow up pain assessment completed. 6. MR review for P7 indicated they had placement of a spinal block. MR review of pain assessment using pain scale of 0 - 10, indicated on 10/30/24 at 8:11 a.m., P7 rated the pain in their back at 5, interventions included breathing techniques and reposition, P7 did not have follow up pain assessment completed. On 10/30/24 at 10:00 a.m., P7 rated the pain in their back at 6, interventions included breathing techniques, reposition, emotional support, and significant other, P7 did not have a follow up pain assessment completed. On 10/30/24 at 7:40 p.m., P7 did not have a pain rating for pain in their abdomen, intervention included splinting, and did not have a follow up pain assessment completed. On 10/31/24 at 5:30 a.m., P7 rated the pain in their surgical incision at 4, intervention included medication, their pain goal was 2, and did not have follow pain assessment completed. On 10/31/24 at 9:45 a.m., P7 rated the pain in their surgical incision at 2, intervention included medication, their pain goal was 2, and did not have follow pain assessment completed. 7. Interview with A4 on 04/16/25 at approximately 4:15 p.m., confirmed P1, P5, P6, and P7 were missing pain reassessments which include pain location and intervention provided.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 48061 Based on document review and interview, facility nursing staff failed to complete required pain assessment and/or reassessment documentation for 1 of 10 patient medical records reviewed. (P1) Findings include: 1. Facility policy titled, “Vital Signs”, no policy number, publication date 2/10/2022, indicated under V. POLICY STATEMENTS: D. Pain Assessments. 3. Pain will be reassessed within 60 minutes of administration of pain management. 2. Facility policy titled, “Adult Pain Management”, no policy number, publication date 08/03/2023, indicated under VI. Procedures. A. Utilize an evidence-based tool to assess pain that is consistent with patient age, condition, and ability to understand. Discuss with patient identified pain goal based on functional ability/status. Lippincott Procedures - Pain assessment. Pain assessment. Documentation. Documentation associated with pain assessment includes: initial assessment findings, reassessment findings (as indicated), date and time of the assessment, assessment tool used, pain or comfort indicators present, description of the patient’s behavior, patient’s activity level, changes since previous measurements, pain management interventions performed, patient’s response to those interventions, progress towards pain management goals. 3. Review of P1’s MR (Medical Record) indicated a physician order dated 11/2/24 at 10:44 am indicated 1 mg (milligram) IV (Intravenous) Dilaudid was ordered as needed for pain every 4 hours. At 3:15 pm on 11/2/24 MD1 ordered Oxycodone 5 mg by mouth every 4 hours as needed for moderate pain, Oxycodone 10 mg orally every 4 hours as needed for severe pain, and Compazine 5 mg IV push every six hours as needed for nausea and vomiting. On 11/3/24 at 4:47 pm 0.5 mg IV Dilaudid was ordered as needed for pain every 4 hours. Miralax 17 g (grams) to be taken orally once daily was ordered on MAR (Medication Administration Record) documentation dated 11/2/24 -11/6/24 indicated P1 received doses of each medication as needed for pain at the patient’s request. P1’s MR lacked documentation of nursing reassessment of pain within 60 minutes of giving medication, and response to interventions of these medication doses including but not limited to Oxycodone 5 mg given orally on 11/2/24 at 6:55 am, Oxycodone 10 mg given orally on 11/3/24 at 6:41 am, 12:17 pm, and 4:44 pm, Dilaudid 0.5 mg given IV on 11/3/24 at 6:11 pm, Oxycodone given orally on 11/3/24 at 6:32 am, and Oxycodone 10 mg given orally on 11/4/24 at 6:32 am. 4. In an interview on 12/5/24 at approximately 12:31 pm am with A2 (Accreditation & Regulatory Consultant) confirmed nursing documentation for P1 related to pain assessments, pain interventions, pain reassessments were not completed per policy, but should have.”